Colostrum Avoidance Practices and Its Associated Factors Among Mothers of Children Aged Less Than 12 Months in Jinka Town, South Ethiopia, 2019

Introduction: Colostrum avoidance is the common nutritional malpractices in developing countries including Ethiopia. Discarding colostrum is the main causes of respiratory disease and diarrheal disease during childhood and contributes to over a million avoidable infant deaths each year and remains a public health problem in developing countries. Despite the fact that it has a negative effect on child health, little is known about the extent of the problem and its contributing factors in South Ethiopia particularly in study area. The aim of the study was to determine the prevalence of colostrum avoidance practices and associated factors among Mothers of children aged less than 12 months in Jinka Town, South Ethiopia. Methods: A community based cross-sectional study was conducted at Jinka Town from March 1 to 30, 2019. A total of 420 mothers having children less than 12 months of age were selected by systematic sampling technique. The data were collected by using pretested interviewer administered and semi-structured questionnaires. The data was entered using EPIDATA 3.1 and exported to SPSS version 23 for analysis. Descriptive statistics, Binary and multivariable logistic regression analysis were done. An adjusted odds ratio with 95% CI at a p-value < 0.05 was estimated to identify statistically signicant variables with colostrum avoidance practices. Results: The prevalence of colostrum avoidance practice was 9.8% [95% CI: (6.9–12.5)]. Delayed initiation of breast feeding [AOR= 9.08(95% CI 4.16-19.83)], Lack of breast feeding counselling [AOR= 2.33(95% CI 1.11-4.87)], Home delivery of index child [AOR= 2.48 (95% CI 1.16-5.27)] and Poor knowledge on breast feeding [AOR=4.55(95% CI 1.95-10.63)] were factors associated with colostrum avoidance practices. Conclusions: Colostrum avoidance practice among mothers of children aged less than 12 months in Jinka town was high. Delayed initiation of Breas feeding, lack of breast feeding counselling, Home delivery and knowledge on breastfeeding feeding practice were factors associated with colostrum avoidance practice. Promoting institutional delivery services and strengthening of breast feeding counselling during antenatal and postnatal child, marital status, religion, ethnicity, occupation of the mother, household’s wealth status, family size and sex of the index child. Maternal health service utilization: ANC visit, BF counseling during ANC visit, place of delivery of index child, mode of delivery of index child and postnatal care. Breast feeding history: delayed initiation of BF and prelacteal feeding practices. Knowledge: mother’s knowledge on BF. Maternal health related factors: medical conditions and breast problem


Introduction
Breastfeeding is considered a proven child survival strategy, and the World Health Organization (WHO) recommends that, the newborns to be put on the breast within an hour after birth [1]. It provides immense immunologic, psychological, social-economic, and environmental bene ts [2]. It also signi cantly reduces a child's risk of developing obesity, type 2 diabetes mellitus and related chronic non-communicable diseases [3]. Furthermore, breastfeeding promotes a child's cognitive development [4]. Early initiation of breastfeeding immediately after birth enhances mother-infant bonding [5]. Moreover, it promotes effective suckling, successful establishment, and maintenance of breastfeeding throughout infancy [6]. However, in different countries including Ethiopia, a signi cant proportion of mothers offer prelacteal feeds to their newborn [7][8][9].
Colostrum is the rst liquid that is produced in the rst few hours after delivery. It is thick, sticky and clear to yellowish in color. It contains proteins, vitamin A and maternal antibodies important to the newborn's nutrition until lactation is fully established [10]. communities from almost 70% to a low of 13% as this is culturally in uenced [18]. Among women in developing countries who do not give colostrum feeds, most of them avoid colostrum feeding based on cultural beliefs that range from no nutritional value for infants to harmful for the infant's health. Some women may specify no reason for avoiding colostrum rather than tradition [19].
Every day, 3000-4000 infants die in the developing world from diarrhea and acute respiratory infections because they were receiving inadequate amounts of breast milk in their feeding and were deprived colostrum [29]. In particular, 45% of neonatal infectious deaths, 30% of diarrheal deaths, and 18% of acute respiratory deaths among children aged less than ve years are associated with suboptimal breast feeding [30,31] .Malnutrition is an underlying factor in more than 50% of the major cause of infant mortality and the risk of malnutrition in children during the rst 2 years of life is an indication of poor infant feeding practices [32] .A Study carried out in Afambo district, Afar found that children who were colostrum avoided had 2.34 times increased likelihood of being underweight when compared to those children who fed colostrum [33]. Suboptimal breast feeding is also one of the risk factor for childhood stunting [34]. Poor infant feeding practices are chief challenges to the social and economic development of one country [35].
Different factors were noted to affect colostrum avoidance practice; it was mainly related to maternal characteristics. Accordingly, home delivery, failure to attend ANC, lack of post-natal care, late breastfeeding initiation and poor knowledge on optimal breast feeding [26,27,36] .
A wide range of harmful new born feeding practices are documented in Ethiopia even after the implementation of infant and young child feeding guideline [37]. In cognizance of the severity as well as the wide spreading practices of inappropriate breastfeeding, the Government of Ethiopia has been devising different strategies including generating of health extension program, and working in collaboration with Non-Governmental Organizations (NGOs) in the areas of IYCF [38,39]. WHO and UNICEF recommend that children should initiate colostrum within the rst hour of birth, However in Ethiopia about 27% of infant had not started colostrum within one hour of birth [40,41]. Despite the fact that colostrum avoidance has a negative effect on child health, little is known about the extent of the problem and its contributing factors in Southern Ethiopia particularly in study area. As there are diverse cultural practices among Ethiopian communities, evidence generated by this study will assist in developing context speci c interventions to halt colostrum avoidance practice and to promote optimal IYCF practice. Therefore, the purpose of this study was to assess the prevalence of colostrum avoidance practices and its associated factors among mothers of children aged less than 12 months in Jinka Town, Southern Ethiopia.
The nding of this study may add knowledge about the magnitude and its determinants of colostrum avoidance and to come up with recommendation on possible intervention for colostrum avoidance and association factors in the study area. This study will also help to health care service provider in their counseling/health education session to strength good breast-feeding practices. It helps Town Health o ce and Zonal Health department by providing relevant information for future planning and interventions of appropriate strategies to promote colostrum feeding. This in turn, may help to reduce the mortality and morbidity rate of infant in Ethiopia. The nding of this study also helps for local NGOs working in the areas of child health to improve optimal breast feeding practices.

Methods And Materials
Study setting, design and period This study was conducted in Jinka Town, South Omo Zone and is situated 755 Km away from Addis Ababa and 525 Km from Hawassa. The Town has an estimated population size of 31226 living in 6 kebeles (the smallest administration unit in Ethiopia). Out of total population 15582 are males and 15644 are females. Out of all female population 6076 are women in the reproductive age group (15-49 year). About 997 of the total population are accounted by children less than one years of age. The Town has 1 hospital, 1 health center and 6 health posts providing health services including maternal and child health care. The town also has 12 private clinic and 13 drug vendors [42]. The study period was from March 1 to 30, 2019.
A community based cross-sectional study was conducted to determine the prevalence of colostrum avoidance and associated factors among mothers of children aged less than 12 months in Jinka Town, South Omo Zone, Ethiopia.

Source population
All mothers of children aged less than 12 months in Jinka Town, South Omo Zone.

Study population
All mothers of children aged less than 12 months in the selected kebeles of Jinka Town during data collection period.

Eligibility criteria
Inclusion criteria All mothers/caregivers of children aged less than 12 months and mothers who had lived for at least for 6 months in the study area.

Exclusion criteria
Those mothers who was seriously ill or unable to give the required information during data collection period.

Sample Size and Sampling Technique
In this study, the sample size is determined by using single population proportion formula. Considering the prevalence of colostrum avoidance practices of 20.3% obtained from previous study conducted in Motta Town [28], 95% certainty and maximum discrepancy of 5% between the sample size and the underlining population. The following single population formula: By using design effect of 1.5 and by adding 15% of non-response rate, total sample size is 249 *1.5 + 15%=430. Thus, the nal sample size was n = 430 mothers.
Systematic sampling technique was employed to select study participants. From total of 6 kebeles of Jinka Town 4 Kebeles was selected by Lottery Method. In order to obtain the sample size from each selected kebeles proportional allocation to sample size was done. First, numbering of all households of selected kebeles with mothers of children aged less than 12 months was conducted, and then systematic sampling technique was applied for selection of study participants. Finally, every k th =2 Mother from each house hold of the selected Kebele's was identi ed until the required sample size ful lled and the starting household was selected using a lottery method. At the time of survey, from each household unit one eligible mother who had a child aged less than 12 months was selected. In scenarios where there was more than one potential respondent in a household, simple random sampling was done to select one.

Study variables
Dependent variable Colostrum avoidance practices Independent variables Socio-demographic factors: age of the mother, educational status of the mother, educational status of father of index child, marital status, religion, ethnicity, occupation of the mother, household's wealth status, family size and sex of the index child. Maternal health service utilization: ANC visit, BF counseling during ANC visit, place of delivery of index child, mode of delivery of index child and postnatal care. Breast feeding history: delayed initiation of BF and prelacteal feeding practices. Knowledge: mother's knowledge on BF. Maternal health related factors: medical conditions and breast problem Operational de nition and terms Colostrum avoidance

Socio demographic characteristics of mothers and children
Four hundred twenty Mothers having children less than 12 months of age were interviewed in this study, with a response rate of 98.4%. The mean age of respondents was 26.86(SD ± 5.06) years. A minimum and maximum age of the respondents was 18 and is the failure to feed infants the rst, thick and yellowish milk that is produced in the rst 3 days after birth. Avoiding colostrum was coded as '1', while colostrum feeding was coded as '0' for regression analysis [26].

Prelacteal feeding
If an infant within the rst three days of life feed something other than breast milk [40].

Delayed initiation of BF
Initiation of breastfeeding after one hour of birth [40].
Good knowledge of breastfeeding practice If a mother answered four questions out of seven on breastfeeding knowledge correctly [28].

Data Collection Tools and Procedure
A semi-structured interviewer administered questionnaire was used to collect data from mothers of a child. The questionnaire was constructed by adapting from previous literature [20,[25][26][27]36] and contextualized to t the research objective accordingly. The questionnaire was initially prepared in English and then translated into Amharic version (local language) by different uent speakers of both languages and then to English to check its consistency. The questionnaire mainly addressed socio-demographic, infant feeding, maternal health services utilization, maternal health related and maternal knowledge on breast feeding practices. The data were collected by four trained diploma nurses who are uent speaker in the local language and supervised by two BSc public health professionals. Face-to-face interview technique was conducted at the study participants' house. The study participants were properly oriented on the purpose, objectives and usefulness of the study and then questionnaire was provided to respondents after getting written consent from each participant.

Data quality control
To assure the quality of data, properly designed data collection instruments was provided after appropriate training for data collectors and supervisors. The questionnaire was initially prepared in English and then translated into Amharic version (local language) by different uent speakers of both languages and then to English to check its consistency. The questionnaire was pretested prior to the actual data collection on 5% of the sample size in nearby Town, Key Afer in order to check clarity and consistency of data collection instruments. During pre-testing an effort was made to check for consistency in the interpretation of questions and to identify ambiguous items. The collected data was checked for consistency, completeness and relevance on a daily basis during the entire data collection by the supervisors and principal investigator.

Data Processing and Analysis
The collected data was coded and entered by EPIDATA 3.1 and exported to statistical package for social science (SPSS) version 23.0 for analysis. Then data cleaning, editing recoding and management were carried out. Descriptive statistics; mean, standard deviation and proportion were done. The household wealth index was computed by considering properties, like selected household assets. The wealth index of participants household was computed by Principal component (PCA). Assumptions for factor analysis were checked. Finally, household wealth status was ranked into three categories (poor, middle and rich). Binary logistic regression analysis was employed to examine the statistical association between the colostrum avoidance practices and independent variables. Variables which have p value < 0.25 during bivariate analysis were entered into multivariable logistic regression to identify statistically signi cant variables. The model goodness of t was tested by Hosmer-Lemeshow statistic which is not signi cant P-value = 0.264. Multi co linearity test was carried out to see the correlation between all multivariate independent variables using collinearity statistics which is tolerance > 0.1 and variance in ation factor < 10. An Adjusted odds ratio (AOR) with 95% CI at a p-value < 0.05 was estimated to identify statistically signi cant variables. The data were presented by tables, frequencies and graphs. The prevalence of colostrum avoidance practices among Mothers The prevalence of colostrum avoidance practices in this study was 41(9.8%) (95% CI: 6.9-12.5). The main reasons for colostrum avoidance were breast milk insu ciency 14(34.1%) followed by considering colostrum causes abdominal discomfort and diarrhea for the new born 11(26.8%). Regarding prelacteal feeding; of the total respondents; 53(12.6%) were practicing prelacteal feeding. The major Reason for prelacteal feeding were; cultural practice 19(35.8%); by considering breast fed for newborns will be thirsty 10(18.9%) and to clean infant's bowel/throat 8(15.1%). Three hundred twenty-four (77.1%) of mothers-initiated breast feeding within one hour, while the remaining 96(22.9%) initiated breast feeding more than one hour (Table 2). Nearly half 198(47.2%) of infants were birth order of second and third child. Around half 208(49.5%) of children were born with birth spacing of greater than 24 months (Table 3).   (Table 4).

Maternal knowledge on breast feeding
From total respondents 290 (69%) of mothers knows about as there is no need to give prelacteal feeding to the infant and 361(86%) of mothers knows about the importance the colostrum the infant. Three hundred fty-two (83.8%) mothers had good knowledge regarding to optimal breastfeeding practice while the remaining 68(16.2%) had poor knowledge concerning optimal breast -feeding practices ( Table 5).

The factors associated with colostrum avoidance practices
In the nal multivariable Logistic regression analysis, the time of initiation of breast feeding, BF counselling, place of delivery and knowledge on breast feeding practices were signi cant factors associated with colostrum avoidance practices. Mothers who delayed initiation of breast feeding were 9.08 times more likely to discard colostrum when compared to mothers who started breast feeding timely within one hour (AOR = 9.08, 95% CI; 4. 16-19.83). Mothers who didn't get breast feeding counselling were 2.33 times more likely to discard colostrum when compared to those mother who get breast feeding counselling (AOR = 2.33,95% CI; 1.11-4.87).
Mothers who delivered the index child at home were 2.48 times more likely to discard colostrum when compared to mothers who gave birth at health facility (AOR = 2.48,95% CI;1. 16-5.29). Furthermore, colostrum avoidance practice were 4.55 times higher among mothers with poor knowledge on breast feeding practices when compared to their counterparts (AOR = 4.55, 95% CI; 1.95-10.63) ( Table 6).

Discussion
This study was aimed to assess the prevalence of colostrum avoidance practices and associated factors among mothers of children aged less than 12 months in Jinka town, South Ethiopia. In this study the prevalence of colostrum avoidance practice was 9.8%. This makes breastfeeding practices sub-optimal in Jinka town due to the introduction of pre-lacteal feeds and to the newborns and due to delayed initiation of rst breast milk.
This result is consistent with the studies conducted in Axum town 6.3% [27],North Wollo Zone 12% [36], Raya Kobo District 13.5% [26] and East Wollega Zone 8.8% [43]. However, the nding of this study was higher than the studies done in Hula district, Sidama Region 3.9% [44]. The difference between these studies might be due to the difference in community attitude towards colostrum feeding among ethnic groups. The other possible reason for this inconsistence of the nding might be sociodemographic difference among study participants.
The nding of this study is also lower than studies done in different developing countries. Utarkhand, India 92% [20], Nepal 16.5% [21], Pakistan 27.9% [45], Burkina Faso 16% [23],South Sudan 38.8% [46] and Debre Tabor 25.6% [25]. This difference could be due to the difference in maternal health service utilization between study populations. The other possible reasons could be due to the difference in year of the study. This could also be the place of residence and difference in maternal educational level. Hence, mothers who reside in the towns would have better access to maternal and child health services.
In this study, Mothers who delayed initiation of breast feeding were about nine times more likely to practice colostrum avoidance than those who initiated breast feeding within one hour. This result is consistent with the study done in Raya Kobo District, North Wollo zone, Pakistan, Nepal and Utarkhand, India respectively [20,21,26,36,45]. This could be because of the fact that those mothers who discarded the colostrum might take more time to discard it and initiate breastfeeding later. The reverse might be also correct. When mothers tend to initiate breastfeeding later, they would have more time for infant feeding malpractices like colostrum avoidance. This might be also due to the fact that when mother delay initiation of breast feeding infants suckling activity decreases and which in turn affects or decreases maternal milk secretion due to decreased breast stimulation, which nally made the mother to give other food to the infant and discard colostrum [28]. This might be due to knowledge gap about the importance of colostrum. The other possible reason might be due to mother's belief by considering colostrum as unclean and bad for the infant's health.
This study showed that mothers who didn't get breast feeding counseling were 2.3 times more likely to discard colostrum when compared to the mothers who get counseling regarding breast feeding. Other studies done in Hula District, Sidama Region and East Wollega Zone showed that breast feeding counseling during antenatal care improves timely initiation of rst breast milk [43,44]. This might be due to that counseling is the tool to change the behaviors of mothers to reduce harmful nutritional malpractice during the time of pregnancy. This could be due to breast feeding counselling during perinatal period may increase mother's awareness on optimal breastfeeding practices that might decrease colostrum avoidance. But study done in Axum town revealed that there were no association between breast feeding counseling during ANC visit and colostrum avoidance practices [27]. This could be due to variation in utilization of maternal health services among study settings.
In this study, Mothers who delivered their index infants at home were 3.48 times more likely to engage in colostrum avoiding practices when compared with those who delivered in health facility. This nding was consistent with study conducted in Raya kobo district, North Wollo Zone, Pakistan and Utarkhand, India [20,26,36]. This indicates that strengthening maternal health service improves optimal breast feeding practices. This could be due to the fact that mothers, who gave birth at home, were more likely to be exposed to the traditional beliefs that favor colostrum discarding. In contrast, utilizing an institutional delivery would have an added bene t to receive immediate obstetric care, such as early initiation of breastfeeding which reduces the likelihood of practicing colostrum avoidance.
The odds of colostrum avoidance were 4.55 times higher among mothers with poor knowledge of optimal breast-feeding practices when compared to their counterparts. This nding was supported by other studies carried out in Axum Town, Raya Kobo District, Hula District and Utarkhand, India [20,26,27,44]. These supporting evidences revealed that improving the mother's awareness of optimal infant feeding practices reduces the likelihood of colostrum avoidance. This might be due to awareness of mothers about breast feeding practices and the nutritional value of colostrum decreases the likelihood of colostrum discarding.
The limitation of this study were that the information obtained from mothers having children aged less than 12 months is subject to recall bias and also It is di cult to establish temporal relationship as the study design was cross-sectional.

Conclusion And Recommendation
Colostrum avoidance practice among mothers of children aged less than 12 months in Jinka town was found to be high when compared to WHO recommendation. Delayed initiation of breast feeding, lack of breast-feeding counselling, home delivery of index child and poor knowledge on breastfeeding feeding practice were signi cant factors associated with colostrum avoidance practices of mothers. Based on the nding the following recommendations' are forwarded; Awareness creation activities on the nutritional value of colostrum, promotion of institutional delivery and improving breastfeeding counseling are important interventions to reduce colostrum avoidance practices in Jinka Town.

Declarations
Ethics approval and consent to participate: The study protocol was approved by the Institutional Review Board (IRB) of College of Medicine and Health Science, Arba Minch University. Based on the approval, an o cial letter of support was written by Arba Minch University Public Health Department to Jinka Town health o ce. At last data was collected after assuring the con dentiality of responses and obtaining informed consent from the study participant. Availability of data and material: For those who are interested; the datasets of this study could be accessed from the corresponding author on reasonable request.
EA conceived and designed the study, supervised the data collection, performed the analysis, interpretation of data and drafted the manuscript. FG assisted in designing the study, data interpretation and critically reviewed the manuscript. MB assisted in data interpretation and reviewed the manuscript critically. All authors read and approved the nal manuscript.